Name of patient :____________________Name of Husband:_________________________

Age :-

Address :- V.P.O.

H/O Menstrual Cycle :-
_____/_____Days, Regular/ Irregular, Av/scant/Excessive,
H/O Dysmenorhoae

L.M.P.______________ E.D.D.______________

Obstetrical History :- Gr._______Para____Ab.______Living Children___ __Male____Female
H/O Any Abortion /mid trimster abortion / M.T.P.
H/O Premature Delivery/Still Birth /
H/O Forcep Delivery/ Ventouse / L.S.C.S ( Indication:-____________________)

Medical History :- H/O P.E.T. / Hypertension / Diabetes / U.T.I. / Koch’s / Thyroidism / myxoedema / Heart disease / Any Other Medical Problem‑

Surgical history :- Any Surgical Operation L.S.C.S. / ___________________________

Investigation :- Hb.______Gms% T.L.C. _________/mm P.___L.____E.____M.___
Bl.Group. A/ B / O / AB + / -
Bl.Sugar ( F ) _______mg% V.D.R.L. _________
Bl.Urea.__________ mg% S.creatinine _______mg%

General Examination :- Anaemia ______Pallor_______edema Feet______
Any Lymphadenopathy._______Thyroid ________
Pulse :-______/mnt B.P.____/______mm Hg.
Systemic Examination :-
C.V.S.:-

Resp.Syst.

G.I.T.:-
Inj T.T. Ist Dose:-______________II nd Dose:-_________________

Date
Ht Of Ut.
Pr.Of Foetus
F..H.S.
Foetal Movem.
anaemia
Oedema
B.P.
Wt In Kg.
U.S.G.


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